Payment Policy:Modifier to Procedure Code Validation: Payment Modifiers Reference Number: CC.PP.028

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1 Payment Policy:: Payment Modifiers Reference Number: CC.PP.028 Product Types: ALL Effective Date: 01/01/2013 Last Review Date: 02/23/2018 See Important Reminder at the end of this policy for important regulatory and legal information. Coding Implications Revision Log Policy Overview Providers append modifiers to procedures codes to indicate that a procedure or service has been altered by some circumstance, but the definition of the procedure or the procedure code itself is unchanged. When a provider bills a modifier that is invalid for the procedure code billed, the claim line containing the invalid modifier to procedure code combination will be denied. This policy is relevant to modifiers identified as affecting payment. The Centers for Medicare and Medicaid Services (CMS), the American Medical Association (AMA) and public-domain specialty societies determine payment modifiers that are appropriate for billing with certain procedure codes. The AMA publishes the Current Procedural Terminology (CPT) HCPCS Level I modifiers and CMS publishes the valid list of HCPCS Level II modifiers. According to the AMA (2016): A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. Modifiers also enable healthcare professionals to effectively respond to payment policy requirements established by other entities (p. 709). Application This policy applies to Professional and Outpatient institutional claims. Policy Description Reimbursement Claims Reimbursement Edit The health plan s code editing software will evaluate individual claim lines for invalid payment modifier to procedure code combinations. The rule will deny procedure codes when billed with a payment modifier that is inappropriate for the service billed or not clinically likely for the procedure code billed. This rule reviews modifier to procedure code combinations on the current claim only and does not review historical claims. Page 1 of 6

2 Rationale for Edit Providers should bill the correct payment modifier for the appropriate procedures. Coding and Modifier Information This payment policy references Current Procedural Terminology (CPT ). CPT is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2017, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from current manuals and those included herein are not intended to be allinclusive and are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. Modifier Descriptor 22 Increased Procedural Services 23 Unusual Anesthesia 24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service 26 Professional Component 27 Multiple Outpatient Hospital E/M Encounters on the Same Date 32 Mandated Services 33 Preventive Service 47 Anesthesia by Surgeon 50 Bilateral Procedure 51 Multiple Procedures 52 Reduced Services 53 Discontinued Procedure 54 Surgical Care Only 55 Postoperative Management Only 56 Preoperative Management Only 57 Decision for Surgery 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period 59 Distinct Procedural Service 62 Two Surgeons 63 Procedure Performed on Infants less than 4 kg 66 Surgical Team Page 2 of 6

3 73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia 74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional 78 Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period 79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period 80 Assistant Surgeon 81 Minimum Assistant Surgeon 82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). 90 Reference (Outside) Laboratory 91 Repeat Clinical Diagnostic Laboratory Test 92 Alternative Laboratory Platform Testing 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System 96 Habilitative Services 97 Rehabilitative Services 99 Multiple Modifiers AA Anesthesia Services Performed Personally by Anesthesiologist AD Medical Supervision by a Physician: More than 4 Concurrent Anesthesia Procedures AR Physician Provider Services in a Physician Scarcity Area AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery QK Medical direction of two, Three, or four concurrent anesthesia procedures involving qualified individuals. QS Monitored anesthesia care service QW CLIA Waived Test QX CRNA Service : With Medical Direction by a Physician QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist. QZ CRNA Service: Without medical direction by a physician TC Technical Component XE Separate encounter, a service that is distinct because it occurred during a separate encounter XP Separate practitioner, a service that is distinct because it was performed by a different practitioner Page 3 of 6

4 XS XU Separate structure, a service that is distinct because it was performed on a separate organ/structure Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service Definitions 1. HealthCare Common Procedure Coding System (HCPCS), Level I Modifiers: Also known as CPT modifiers consisting of two numeric digits. These modifiers are in the range of The list is updated annually by the AMA. 2. HealthCare Common Procedure Coding System (HCPCS), Level II Modifiers: Also known as the HCPCS modifiers and consist of two alpha-numeric characters. These modifiers are in the range of AA-VP. The list is updated annually by the CMS. 3. Modifier: Two digit numeric or alpha-number descriptor that is used by providers to indicate that a service or procedure has been altered by a specific circumstance, but the procedure code and definition is unchanged. 4. Modifiers Affecting Payment: Modifiers which impact how a claim or claim line will be reimbursed. Related Policies [Insert text or Not Applicable ] Related Documents or Resources [Insert text, hyperlinks, or Not Applicable ] References 1. Current Procedural Terminology (CPT ), HCPCS.html 3. HCPCS Level II, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), ICD-10-CM Official Draft Code Set, Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services. Revision History 09/09/2016 Corrected Modifier definitions for QW and QX 02/24/2018 Converted to updated template, conducted review, removed Modifier -21; Added Modifiers: -23,-32,-47,-63,-77,-90,-92,-95,-96,-97,-99,-QS,-XO,- XP,-XS,-XU Important Reminder Page 4 of 6

5 For the purposes of this payment policy, Health Plan means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan s affiliates, as applicable. The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable plan-level administrative policies and procedures. This payment policy is effective as of the date determined by Health Plan. The date of posting may not be the effective date of this payment policy. This payment policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this payment policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. Health Plan retains the right to change, amend or withdraw this payment policy, and additional payment policies may be developed and adopted as needed, at any time. This payment policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This payment policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this policy are independent contractors who exercise independent judgment and over whom Health Plan has no control or right of control. Providers are not agents or employees of Health Plan. This payment policy is the property of Centene Corporation. Unauthorized copying, use, and distribution of this payment policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this payment policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this payment policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and Page 5 of 6

6 LCDs should be reviewed prior to applying the criteria set forth in this payment policy. Refer to the CMS website at for additional information Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 6 of 6